4. Definition:
Anemia is defined as a reduction of
the red cell volume (hematocrit) or
hemoglobin concentration below the
range of normal values for age.
5. World Health Organization (WHO) has
suggested levels of Hb below which
anaemia is said to be present.
*These levels are:
<11 g/dL in children aged 6 months
-<6Y
<11.5 g/dL in children aged 6-<12 years
<12 g/dl in older children (aged 12-14).
6. Childhood anaemia poses a major public health
issue leading to an increased risk of child
mortality, as well as the negative consequences of
iron deficiency anaemia on cognitive and physical
development.
7. Dietary sources of iron
• Rich :liver,dry beans
• Medium:meat,chicken,fish, spinach, banana,
apple
• Poor:milk and its products, vegetables
8. Haeme iron is better absorbed, but forms a
smaller fraction of the dietary iron(6%).
• Dietary iron :Haeme or non haeme /Inorganic
iron
• Non haeme iron and iron in inorganic form is
present as ferric iron must be first reduced to
ferrous iron .
9. • Dietary iron mostly in the ferric form (Fe3+)
In the stomach Fe3+ - Fe2+
In the mucosal cells Fe2+ Fe3+ Apoferritin
Ferritin ( Stored) Iron slowly released
In the plasma Fe2+ Fe3+ with Transferrin
Iron bound transferrin Transfers iron to
bone marrow , Liver , Spleen ( Stored)
10. Absorbed from the duodenum (where most drugs are
absorbed) and upper jejunum.
Only 10% of dietary iron is absorbed
In circulation:
iron is carried in ferric form
bound to transferrin (only 35% of transferrin is saturated
with iron)
11. –Facilitated by • Acidic pH of stomach , Ascorbic
acid •
–Inhibited by • Excess phosphates, oxalates,
Phytates • Milk, antacids, tetracycline ↓ iron
absorption by forming insoluble complexes
12. Hemoglobin.
Heme enzymes, e.g., cytochromes, catalase,
peroxidase
Myoglobin
Metalloflavoprotein enzymes such as xanthine
oxidase
The mitochondrial enzyme alpha-
glycerophosphate oxidase and other
mitochondrial enzymes.
Other enzymes and processes
13. FT baby: with store enough for 4 mo
PMT baby: with store enough for 2 mo
1mg/kg/day elemental iron for infants and
children (max 15 mg/day)
2 mg/kg/day elemental iron for low birth weight
and newborns with very low initial Hb values
6 mg/kg/day elemental iron is needed for tt for 3
mo
14. Most common nutritional deficiency in
children and is worldwide.
More common at:
● 6 - 24 months
● artificially fed infants.
● low socioeconomic status
15. !. Inadequate supply of iron.
A. Inadequate iron stores at birth:
Premature.
multiple births.
Severe maternal iron deficiency.
Fetal blood loss.
B. LOW INTAKE: PERSISTENT MILK INTAKE
II. Impaired absorption of iron:
chronic diarrhea and celiac disease.
III. Excessive demands for iron:
A.Blood loss during infancy:
Cow milk allergy.
Acute or chronic hemorrhages.
Parasitic infestations as hook worms.
16. Inadequate dietary intake:
Early cow milk.
Exclusive breast feeding after 6 months.
Low intake
Failure to meet increased demands
for growth:
premature.
adolescence.
17. ↓ iron stores.
↓ iron‑storage protein (ferritin)
↓ serum iron
↑iron binding capacity TIBC.
Anemia: hypochromia,microcytosis.
↓ activity of iron‑containing intracellular
enzymes (e.g. CNS -MAO).
18. POSTIVE HISTORY OF THE CAUSE +
1- General manifestations of anemia
2- Particular findings effect of iron def. on
systems:
GIT: Anorexia, atrophic glossitis,
dysphagia, Pica (ingestion of wall plaster,
clay)
CNS: Short attention span, irritability,
breath holding, ↓ alertness, ↓ learning
ability and school performance.
Epithelial structures :in adults such as
spoon shaped or concave nails and brittle
nails.
19. A. (CBC) :
Hypochromic microcytic anemia
↓ Hematocrit.
Hb< 9 g/dl.
Red cell count 3 ‑ 5 millions/mm3 (slightly).
Red blood cell indices : All are ↓: but FEP is ↑
↓ MCV: < 78 fl (N 78-95 fl)[fl = 10-15L.
↓ MCH: < 26 pg (N 26-32 pg) [pg = 10-12 g]. ,
RDW >14.5%, ↑FEP >40mg/dl
↓ MCHC: < 30 g/ dl (N 32-36 g/dl).
Reticulocytes usually N. Platelets ↑ or ↓
21. IRON replacement TREATMENT (oral, IM, IV)
TREAT THE CAUSE
Treatment of etiology :
correct diet and treat Ancylostoma.
22. The ability of the patient to tolerate and absorb
medicinal iron is important
Gastrointestinal tolerance to oral iron is
limited
Mainly absorbed only in the upper small
intestinal (delayed-release preparations ?)
Heme iron better absorbed (as part of
myoglobin)
Nonheme iron not well absorbed - bulk of
dietary iron
23. can be given in 2 routes
– Orally –
Parenterally
24. These preparation are mostly available as
ferrous(Fe+2) and some in ferric(Fe+3)form
Ferrous salt are better absorbed than ferric
salts
25. Iron is poorly absorbed in the form of carbonate,
citrate and pyrophosphate, colloidal iron and iron
carbohydrate complex
FORMS :
Tablets, capsules
Sugar coated & uncoated tablets •
Slow release tabs
chewable tabs •
Drops &syrups—used by children's
26. 1. Ferrous sulphate: 20 – 32% iron
2. Ferrous fumarate: 33% elemental iron
3. Ferrous gluconate : 12% elemental iron
4. Colloidal ferric hydroxide:50% elemental iron •
Other oral preparations are ferrous choline
citrate , ferric ammonium citrate , iron calcium
complex, iron hydroxy polymatose.
FERRIC
HYDROCHLORIDE
POLYMALTOSE
27. It is rapidly absorbed, with a high rate of iron utilization
and produces an effective increase in Haemoglobin. Due
to its favourable nonionic nature it has the following
properties unlike ionised iron salt preparations: · Ferose
does not give rise to irritation of the intestinal mucosa
and does not stain the teeth. · Ferose has palatable, non
metallic taste (Ferose chewable tablets have chocolate
flavour and are acceptable even by the most resistant
patients of all ages). · Ferose has excellent tolerance.
28. Oral Iron salts: 6 mg/kg/day elemental for 3 ms/3
doses.
Ferrous sulfate drops for infants
Ferrous gluconate drops ( 12 % elemental iron).
ferrous fumarate tablets or syrup for older
children.
Iron better between meals.
AVOID FOOD DECREASE ABSORPTION: fibers
(e.g. whole bread and cereals), tannate (like
tea), phosphates (in bread, cow's milk and egg
yolk) and phytic acid ↓ absorption of iron.
absorption ↑ by vitamin C (e.g. citrous fruits),
sugar and amino acids (meat, poultry, fish).
29. • Important points to remember ;Elemental iron
content and not quantity of iron compound per unit
dose to be considered
Sustained released preparations expensive and
irrational
Liquid formulations: should be put on back of
tongue and swallowed
30. Ferrous sulfate –least expensive – treatment
of choice
Ferrous salts (sulfate, fumarate, gluconate,
succinate) are absorbed about three times as
well as ferric salts.
Vitamin C increases absorption - Ascorbic
acid, 200 mg or more, increases absorption
by at least 30% (with increased incidence of
side effects too)
Carbonyl iron: microspheres of pure iron –
less gastrointestinal toxicity than iron salts
31. • Constipation (BLACK) is common than diarrhea
• Epigastric pain
• Vomiting
• Heart burn
• Metallic taste
• Nausea
• Staining of teeth.
32. • Oral iron is not tolerated
• Failure to absorb oral iron
• Non compliance to oral iron
• In presence of severe deficiency with chronic
bleeding
33. • Parenteral iron therapy needs calculation of total
iron requirement of the patient –
Iron requirement (mg) = 4.4 X Body wt (Kg) X Hb
deficit g/dL
34. 1. Iron dextran (Imferon): I.V/ I.M
2. Iron sorbitol citric acid complex: Only I.M 3. Iron
carbohydrate complex : I.M
4. Sodium ferric gluconate: Recently approved
preparation for I.V use has much lower risk of
anaphylactic reaction than iron dextran
35. • Iron dextran and iron sorbitol both contain 50
mg/mL recommended dose is 100 mg daily 2 mL
on alternate days until total required dose is
administered or maximum 2 g .
To prevent staining to skin given deep I.M in
buttock using z track technique
Elemental iron 100 mg (As Ferric
hydroxide polymaltose complex)
36. • Intramuscular: – Local pain at site , pigmentation
of skin , sterile abcess
– Systemic: headache, fever, arthralgia,
backache, tachycardia, flushing hemolysis and
collapse these effects are probably due to
excessive amount of free iron in plasma
– Iron sorbitol may cause disorientation and
temporary loss of taste, urine turns black on
standing
37. • Iron dextran after test dose 0.5 mL iron dextran
injected I.V over 5 to 10 min
• Total dose required diluted in 500 mL NS &
infused slowly over 6 to 8 hours under supervision
• If required amount greater than 50 mL given on
two consecutive days
39. 1. Stomach wash with 1% NaHCO3 to render it
insoluble and remove undissolved iron tablets
2. Desferrioxamine Mesylate 5 to 10 g in 100 mL
isotonic saline or calcium sodium edetate 35 to 40
mg/Kg to retard the absorption from GIT
3. Early replacement of fluids and electrolytes,
correction of metabolic acidosis and hypotension by
vasopressors
4. I.v desferrioxamine infusion
5. Diazepam and other anticonvulsants if epileptic
40. • Potent specific chelator of iron binds ferric iron to form
ferrioxamine a stable water soluble chelate
• Ferrioxamine is excreted 2/3 in urine and 1/3 in bile
colors urine reddish brown
• Removes iron from hemosiderin except that in bone
marrow
• Well tolerated rapid I.V may cause hypotension,
anaphylactic reactions and tachycardia
• Allergic reactions and cataract known with chronic
administration
• Contraindicated in renal disease anuria